RN Navigator - Pre​/Post Surgical Optimization

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Mass General Brigham Community Physicians, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary This is a hybrid position that requires three days per week on-site at Newton Wellesley Hospital.

This is an exciting opportunity to join the Mass General Brigham Population Health Services Organization (PHSO) as a Registered Nurse Navigator (RNN) focused on high-risk and medically complex surgical patients within the CMS Transforming Episode Accountability Model (TEAM). This is a mandatory, episode-based, alternative payment model, in which Mass General Brigham will coordinate optimal care for traditional Medicare patients undergoing one of five specified surgical procedures and assume responsibility for the cost and quality of care from surgery through the first 30 days after the patient leaves the hospital.

The model aims to improve the patient experience preoperatively, through surgery and recovery. This will be done by supporting the coordination and transition of care between providers and promoting a successful recovery that can reduce unnecessary post-acute care utilization and readmissions.

The RNN will support multidisciplinary management of patients with elevated clinical complexity across the pre-operative and post-discharge phases. As part of the larger Navigator team that includes Physical Therapy Navigators (PTN), patient coordinators, and Advanced Practice Providers (APPs), they will complement the workflows and patient support by addressing higher-acuity needs, promoting appropriate care pathways, support APPs and geriatricians in managing high risk patients, and improving outcomes across the episode of care.

Under the direction of the team’s Program Manager, the RNN will support management of medically complex cases (e.g., CABG and major bowel), representing a meaningful subset of total volume that require enhanced clinical navigation support. This role also supports a team-based model and improves efficiency, complementarity, and coordination across PTN and APP roles. The RNN panel and workflow is based on patient risk, complexity, and clinical need.

Primary Responsibilities:

The PHSO, with stakeholders across Mass General Brigham, is developing standard, patient-centered episodic operational pathways and workflows to support care delivery and outcomes. Program development is informed by evidence-based learnings and best practices.

Program goals include mitigation of risk, patient optimization, reduced length of stay as appropriate throughout the pathway, continuity of care, and positive long-term health outcomes.

The RNN will be responsible for:

Management of high-risk and medically complex patients across pre-operative and post-discharge phases

Pre-operative clinical assessments, functional and social evaluation of patients

Perform medication reconciliation as part of pre-operative optimization

Risk identification requiring escalation or intervention

Pre-operative clinical, functional, and social assessment utilizing Risk Assessment and Prediction Tool (RAPT) and FRAIL Assessments, and may include other tools as determined appropriate

Collaboration with Coordinators, PTNs, APPs, physician offices (surgeons, specialists, PCPs), inpatient care teams to ensure coordinated episode management

Support post-discharge follow-up, anticipatory guidance, patient education, and clinical triage for complex cases.

Projection of expected hospital course for identified surgical patients, including identification of possible barriers to timely/efficient discharge and/or discharge destination

Communication across internal and external providers, inpatient teams, and post-acute services

Participation in quality/process improvement and program development…